SHA24/002003ppt

Saphenous Vein Graft Vs. Radial Artery Searching for the Second-Best Coronary Artery Bypass Graft

(Long Term Outcome) Hilal Alsabti, MD,MSc, FRCSc Deputy Director General, and Head Of Cardiothoracic Surgery Sultan Qaboos University Hospital

• • • • • •

Introduction.

Historical Prospective.

Harvesting Technique.

Early and mid-term Outcome.

Long term outcome.

Conclusion.

• Over 800,000 patients undergo CABG every year.

• The long term outcome after CABG depends on graft patency.

• Many Grafts Options are available: – – – – –

Internal thoracic Artery.

Saphenous vein graft.

Radial artery.

Right gastroepipolic artery.

Inferior Epigastric artery.

LITA to LAD ( Best): – Best graft patency.

– Better survival.

– Less re-intervention rate.

Advantages and Disadvantages of different conduits as a second graft to LIMA Advantages: • SVG: good handling, enough length, less transfusion and harvest time compared to BITA. • RA: Long, good handling, Luminal diameter close to Coronary, less transfusion and time then BITA. • RITA: excellent long term results, less spastic graft any territory as a composite graft.

• GEA: Graft to any territory as in situ, available in redo.

Disadvantages: • Poor short and long term patency, varix pt. , post op leg oedema, poor wound healing.

• Very spasmodic, not always available, arm wound.

• More bleeding , more sternal infection, thin arterial wall not good for aorto-coronary bypass.

• More spasmodic, same as SV patency, different sizes .

Historical Perspective: • RA was first used by Carpentier in 1971.

• Stopped two years later because of 35% incidence of narrowing and occlusion due to: – Spasm.

– Intimal hyperplasia after endothelial denuation.

– Due to trauma of skeletonization.

• It was revived on 1989 by Acar and his group after modifying the harvesting techniques the solution used.

Preoperative Evaluation: • Preoperative Evaluation: – Allen Test( to check the ulnar collateral circulation) – Pulse oximetry.

– Duplex scan.

• Preoperative contraindications: – Forearm ischemia.

– Calcification.

– Dissection from prior cannulation.

Harvesting Technique: • Harvesting: open or endoscopic.

• With or without ultrasonic scalpel.

• Pharmacological preparation: – Nitroglycrin.

– Ca Channel blocker ( Diltiazem).

– Phosphodiasterase Inhibitor (papaverine).

– Verapamil and nitroglycerin (VG solution).

• Common Complication: sensory abnormality and numbness.

Radial Artery

• I guess only Cleaveland clinic reported worse graft patency of RA compared to SV.

Kaplan-Meier curves of cumulative patency rates according to type of . bypass graft

Khot U N et al. Circulation 2004;109:2086-2091

Early Results: • Early Results always depend on Many factors: • • • • • • • •

Quality of coronary anastomosis.

Endothelial integrity.

Intra-operative handling.

Preservation of conduit before usage.

Pharmacological treatment to prevent spasm.

Low cardiac output, high inotropic support.

Degree of the native graft stenosis.

Distal beds.

Early and Mid-term Results showed excellent graft patency rate

T. Athanasiou et al EJCTS 40 2011

T. Athanasiou et al EJCTS 40 2011

Many Observational Retrospective studies:

Sajja et al, ATS ,2005

Sajja et al, ATS ,2005

Clinical Trials: RAPS • 561 pts in 13 centers.

• Pts underwent CABG with SVG and RA in opposite territory.

• 1 year angiography.

• 440 pts.

Results: • 8.2%RA and 13.6% SVG graft failure.

• Diffuse narrowing of the graft present in 7% RA and 0.9% SV. • Absence of sever native vessel stenosis is a risk factor for RA occlusion.

• Patency of RA in both Cx and RCA is the same.

Clinical Trials: RAPS Multivariate Predictor of graft failure:

• RA occlusion is similar between males and females. While it is more in Females in SV. • RA occlusion is less in diabetic then the SV. • PVD is associated with higher risk of RA graft failure.

The Radial Artery Vs SVG patency (RSVP) • Single center trial.

• Prospective Randomized.

• 5 years patency rate.

• 142 enrolled, 105 had Angio.

• Graft patency , 98.3% of RA compared to 86.4% SV. • Graft narrowing is 10% in RA compared to 23% in SV.

Collins et al, Circulation.2008; 117: 2859-2864

Graft patency at 5 years

Collins P et al. Circulation 2008;117:2859-2864

Mid and long term studies :

Acar et al: 5-20 years experience: At 7 years: patency rate • LIMA 83%.

• RIMA 87%.

• RA 83%.

• SVG 81%.

RA patency is : • Diagonal 93%.

• Cx 82.5%.

• RCA 77.6%

Acar et al. Eur J Cardiothorac Surg. 2012 January; 41(1): 87–92

.

Kaplan—Meier survival following coronary bypass with the radial artery.

Overall survival and freedom form cardiovascular death were 70% and 89% at 15 years respectively

Hoffman et al,

• • • • • •

Circulation. 2012 Sep 11;126(11 Suppl 1):S170-5

16 years experience.

RA patency 82% SV 47% .

LITA 85% RITA 80% .

Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively.

RA patency was not different from LITA patency (P=0.3).

Radial Artery Conduits Improve LongTerm Survival After CABG

Hoffman et al,

Circulation. 2012 Sep 11;126(11 Suppl 1):S170-5

Kaplan-Meier–estimated disease progression rates in all territories with patent conduits

Ann Thorac Surg 2012;94:475-481

Kaplan-Meier–estimated disease progression rates with patent conduits in the lateral territory.

Ann Thorac Surg 2012;94:475-481

Kaplan-Meier–estimated overall freedom of disease progression and graft failure.

Ann Thorac Surg 2012;94:475-481

Kaplan–Meier curve for late survival for multiple arterial grafting (MultArt) subgroups vs left internal mammary artery (LIMA)/saphenous vein (SV) unmatched groups: bilateral internal ... mammary artery (BIMA)/SV (dashed dotted line) vs LIMA/SV (solid line); ha

Locker C et al. Circulation 2012;126:1023-1030 Copyright Š American Heart Association

Kaplan–Meier curve for late survival for multiple arterial grafting (MultArt) vs left internal mammary artery (LIMA)/saphenous vein (SV), propensity score–matched groups: MultArt ... (dashed line) vs LIMA/SV (solid line); hazard ratio, 0.73; 95% confidence inte

Locker C et al. Circulation 2012;126:1023-1030

Copyright © American Heart Association

Possati et al, Circulation.2003; 108: 1350-1354

Long-term RA graft status in relation to target-vessel . stenosis

Possati G et al. Circulation 2003;108:1350-1354 Copyright Š American Heart Association

In Conclusion: • Radial Artery is an excellent graft that should be used.

• RA is superior in many single centers with long term results.

• There is a high incidence of Occlusion of the RCA no matter what you put in it.

• More evidence from large scale multi-centric trials needed.

Thank You